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Digestive System 3
Lecture 13
Pathology and Clinical
Science 1 (BIOC211)
Department of BioscienceText Reference:
Grossman, S.C. & Porth, C.M. (2014). Porth’s Pathophysiology: concepts of
altered health states, (9th ed.). Philadelphia, U.S.A. Walters Kluwer Health -
Lippincott, Williams & Wilkins.
© endeavour.edu.au
© Endeavour College of Natural Health endeavour.edu.au 2
SESSION LEARNING OBJECTIVES
Understand the normal function lower tract small and
large intestines
Understand the causation, clinical features, treatment
aims and prognosis for the following conditions
Pancreas
• acute and chronic pancreatitis
Small intestine/ Large intestine
• Inflammatory Bowel Disease,
• Irritable Bowel syndrome
© Endeavour College of Natural Health endeavour.edu.au 4
OVERVIEW SMALL INTESTINE
o Small bowel function
• absorption carbohydrate (CHO), protein, lipids,
calcium, B12, iron (Fe)
o Small bowel disorder - clinical features
• diarrhoea,
• abdominal pain - site
• bloating
• weight loss
• nutritional deficiencies
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SMALL BOWEL INVESTIGATIONS
o Blood Full Blood Evaluation (FBE), proteins,
calcium, B12
o Autoantibodies, endomysium, tissue
transglutaminase, reticulin, gliadin
o Barium follow through
o Jejunal biopsy
o 3 day fat collection (100 gm fat intake)
o Lactose intolerance (intake of 50 gm lactose)
© Endeavour College of Natural Health endeavour.edu.au 6
PANCREATITIS
Inflammation and oedema of pancreatic tissue caused by
presence of intracellular proteases, often initiated by high
intracellular levels of Calcium, causing mild fat necrosis or
severe necrosis and haemorrhage
Can be acute or chronic
Cause - majority 90%
• gallstones causing reflux of bile into pancreatic duct
so activating trypsin
• alcohol by stimulating secretion and blocking
sphincter that releases enzymes into small intestine
• other causes (rare) idiopathic, infections, iatrogenic
(post Endoscopic Retrograde
Cholangiopancreatography (ERCP), drugs, trauma
© Endeavour College of Natural Health endeavour.edu.au 7
ACUTE PANCREATITIS Clinical Features
• epigastric & abdominal pain increasing in severity over
15-60 minutes often following intake large meal or alcohol
• nausea & vomiting
• signs of shock
• low grade fever
• abdominal distention, tenderness, guarding,
• reduced or absent bowel sounds
Investigations
• serum amylase levels (x3), serum lipase
• FBE, ESR & C-Reactive protein
• plain X-ray, Ultrasound, contrast CT Scan
© Endeavour College of Natural Health endeavour.edu.au
ACUTE PANCREATITIS
From Essential Pathology. (3rd ed., p. 444) by Rubin E.. 2001. Philadelphia. Lippincott, Williams & Wilkins
© Endeavour College of Natural Health endeavour.edu.au 9
ACUTE PANCREATITIS
From Essential Pathology. (3rd ed., p. 444) by Rubin E.. 2001. Philadelphia. Lippincott, Williams & Wilkins
© Endeavour College of Natural Health endeavour.edu.au 10
ACUTE PANCREATITIS
http://www.pathologyoutlines.com/images/pancreas/7_02.jpg
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ACUTE PANCREATITISo Treatment
• usually emergency
• no oral intake, but restoration of lost plasma via I.V route
• Analgesia
• oxygen therapy / gastric suction
o Complications - 10% mortality
• abscess formation, pseudocyst, necrotizing pancreatitis
• obstruction of head of pancreas or duodenum
• haemorrhage
• chemical peritonitis
• shock
• septicaemia
© Endeavour College of Natural Health endeavour.edu.au 12
PANCREATIC ABSCESS
http://www.health-res.com/EX/07-31-12/2119.fig7.jpg
Abscess
Pancreas
© Endeavour College of Natural Health endeavour.edu.au 13
CHRONIC PANCREATITIS
Chronic intra pancreatic enzyme activity leading to
fibrosis
Cause
• Alcohol - 60 - 80%, cystic fibrosis, inherited defect
Clinical Features
• episodic pain radiating to back
• anorexia, weight loss, diarrhoea
• Signs of diabetes and malabsorption
Investigations – Ultrasound, contrast CT, Magnetic
retrograde cholangiopancreatography (MRCP)
Treatment - NSAIDS, analgesia, tricyclics, oral
pancreatic enzymes, low fat diet
© Endeavour College of Natural Health endeavour.edu.au 14
CHRONIC PANCREATITIS
From Essential Pathology. (3rd ed., p. 446) by Rubin E.. 2001. Philadelphia. Lippincott, Williams & Wilkins
© Endeavour College of Natural Health endeavour.edu.au 15
CHRONIC PANCREATITIS
http://www.pathologyoutlines.com/images/pancreas/7_01.jpg
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INFLAMMATORY BOWEL
DISEASE
Crohn’s (CD) & Ulcerative Colitis (UC)
• Inflammation of intestine - immune mediated
• Occurs more in western groups
• Male / female affected, slightly more female than male
in Crohn’s
• Cause unknown but current findings suggest a genetic
susceptibility with an environmental trigger
• Episodes of remission & exacerbations
• UC has risk for colorectal cancer
© Endeavour College of Natural Health endeavour.edu.au 17
INFLAMMATORY BOWEL DISEASEFindings and Theories under research
Familial tendency
Both CD and UC
Dietary factors
Butyric acid, sulphides
Omega 3 fatty acids
Smoking
High in CD / ex-smokers UC
Infective agents
Mycobacterium paratuberculosis, measles, yeasts, Listeria & Helicobacter species
Familial tendency
Both CD and UC
Endogenous bacteria
Suggestion bacteroides and strains of E Coli initiate & continues the inflammation
Immunological factors
Inability to down regulate immune response esp. to endogenous luminal antigens
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INFLAMMATORY BOWEL DISEASE
Oesophageal Crohn’s
http://www.sciencephoto.com/image/390509/53
0wm/C0096124-
Crohn_s_disease_in_the_oesophagus-SPL.jpg
Crohn’s Disease
o Thickened narrowed small intestine
o Any area of GI tract, affected more
commonly in terminal ileum, or (R)
side of colon
o Initial ulceration of mucosal layer is
affected then deepens to involve all
layers (transmural) may develop to
form fistulas, abscesses or
adhesions
o Skip lesions
o Cobblestone appearance
o Granulomas present
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CROHN’S DISEASE
From Essential Pathology. (3rd ed., p. 378) by Rubin E.. 2001. Philadelphia. Lippincott, Williams & Wilkins
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CROHN’S DISEASE
From Essential Pathology. (3rd ed., p. 381) by Rubin E.. 2001. Philadelphia. Lippincott, Williams & Wilkins
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CROHN’S DISEASE
From Pathophysiology for the Health Professions. (2nd ed) by Gould B. 2002. W B
Saunders Company
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INFLAMMATORY BOWEL
DISEASE
http://www.sciencephoto.com/image/415157/530w
m/C0103581-Ulcerative_colitis-SPL.jpg
Ulcerative Colitis
• Spreads proximally
• May affect
– rectum - proctitis
– Sigmoid - proctosigmoiditis
– Whole colon - pancolitis
• only mucosa and submucosa
layers affected
• mucosa reddened, inflamed,
bleeds easily
• inflammatory cells in lamina
propria and crypts
© Endeavour College of Natural Health endeavour.edu.au 23
ULCERATIVE COLITIS
From Essential Pathology. (3rd ed., p. 382) by Rubin E.. 2001. Philadelphia. Lippincott, Williams & Wilkins
© Endeavour College of Natural Health endeavour.edu.au 24
Complications
of Ulcerative
Colitis
From Essential Pathology. (3rd ed., p. 383) by Rubin E.. 2001. Philadelphia. Lippincott, Williams & Wilkins
© Endeavour College of Natural Health endeavour.edu.au 25
COMPARISONS
From Basic Pathology. (6th ed., p. 501) by Kumar V, Cotran R & Robbins S. 1997.
Philadelphia. W B Saunders Company
© Endeavour College of Natural Health endeavour.edu.au 26
INFLAMMATORY BOWEL
DISEASE
Investigations
• Stool cultures
• Barium follow through
• FBE ESR, Fe studies
• C reactive protein
• Colonoscopy not in acute stage
• Ultrasound
• Radionuclide scans
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IBD - CLINICAL FEATURES
o Crohn's Disease
• 15% have no GIT
symptoms
• wt loss
• mouth ulcers
• anaemia
• diarrhoea -
• cramping pain
• R iliac fossa mass if colon)
• melaena
• malabsorption picture
o Ulcerative Colitis
• urgency and frequency
of stool > 6 per day,
may be as high as 20
• watery bloody
diarrhoea, mucus may
be present
• low cramping
abdominal pain
© Endeavour College of Natural Health endeavour.edu.au 28
INFLAMMATORY BOWEL
DISEASE Treatment
• Anti inflammatory medications e.g. glucocorticoids,
amino salicylates - Sulphasalazine,
immunosuppressants - azathioprine
• Remove trigger factors e.g. emotional and stress
triggers
• Nutritional supplements / I.V administration of
hypertonic glucose solutions with amino acids and
fats.
• Prevent complications
• Surgery – drainage of abscess/ repair of fistulas
© Endeavour College of Natural Health endeavour.edu.au 29
IRRITABLE BOWEL SYNDROME
A syndrome or collection of bowel symptoms present
with no structural or biochemical abnormalities
(functional disorder)
• 1 in 5 persons have symptoms of IBS
• 50% seek professional medical advice, more
female than men 3:2
• Non-GIT conditions may be present eg Chronic
Fatigue Syndrome, Fibromyalgia, TMJ joint
dysfunction
• Often stress related
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IRRITABLE BOWEL
SYNDROMEClinical Features
• Persistent or recurring abdominal pain / discomfort /
distension / bloating
• Altered bowel function
• Flatulence
• Constipation / diarrhoea
• Nausea & anorexia
• Anxiety or depression
Triggers include -
• GIT infection, antibiotic therapy, pelvic surgery ,
psychological stress
© Endeavour College of Natural Health endeavour.edu.au 31
IRRITABLE BOWEL SYNDROMEDiagnostic Criteria
o 12 consecutive weeks of abdominal pain in 1 twelve month period
o To include 2 of the following 3 symptoms
• Symptoms relieved by defecation
• Onset change of frequency of stool
• Onset change in form of stool
Treatment
o Organ Treatment,
• Dietary triggers, fibre, anti-diarrhoeal, smooth muscle relaxants,
o Central Treatment
• Physical explanation of symptoms
• Counselling, psychotherapy, hypnotherapy, cognitive behavioural therapy, antidepressants
© Endeavour College of Natural Health endeavour.edu.au 32
IRRITABLE BOWEL
SYNDROME
Treatment continued…..
• Increased fibre in diet except in acute stage
• Avoid dietary triggers (gas producing
foods)
• Antispasmodic / anticholinergic drugs
• Alosetron – a 5-HT3 antagonist
• Surgery – drainage of abscess/ repair of
fistulas
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APPENDICITIS
Epidemiology
Extremely common
12% males and 25% females in USA
Pathologenesis
Related to intraluminal obstruction with:
faecalith/ gallstone/ tumour/ parasites or lymphatic tissue
Appendix becomes inflamed, swollen and gangrenous
Perforates if not treated
© Endeavour College of Natural Health endeavour.edu.au 34
APPENDICITISClinical Features
Sudden onset of referred epigastric or periumbilical pain.
Pain becomes colicky and localised to lower (R) quadrant.
Deep tenderness
Spasm of abdominal muscles and guarding
Nausea / vomiting
Diagnosis / Investigations
Patient history
Ultrasound
Complications
Peritonitis / periappendiceal abscess formation/ septicemia
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INFLAMMATION OF APPENDIX
http://biology-forums.com/gallery/14755_26_10_12_5_22_58_96792213.jpeg
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INFLAMMATION OF APPENDIX
http://www.iupui.edu/~pathol/c603_General/labs/Inflammation%20Lab/lab_images/720edb.jpg
© Endeavour College of Natural Health endeavour.edu.au 37
Readings and ResourcesResources:
o Set Textbooks:
Colledge, N.R., Walker, B.R. & Ralston S.H. (2014). Davidson’s Principles and Practice of Medicine, (22nd ed.). Edinburgh.
Churchill Livingstone.
Grossman, S.C. & Porth, C.M. (2014). Porth’s Pathophysiology: concepts of altered health states, (9th ed.). Philadelphia,
U.S.A. Walters Kluwer Health - Lippincott, Williams & Wilkins.
o Additional textbooks:
Davies, A. & Moores, C. (2010). The respiratory system: basic science and clinical conditions, (2nd ed.). Edinburgh. Churchill,
Livingstone, Elsevier.
Field, M., Pollock, C., Harris, D. (2010). Systems of the Body: The Renal System; Basic Science and Clinical Conditions. (2nd
ed.). United Kingdom: Churchill Livingstone.
Jamison, J.R. (2006) Differential Diagnosis for Primary Care: a handbook for health care practitioners. (2nd ed.). Edinburgh.
Churchill Livingstone.
Lee, G. & Bishop, P. (2013). Microbiology and Infection Control for Health Professionals, (5th ed.). Frenchs Forest, NSW.
Pearson Education.
McCance, K.L. & Huether, S.E. (2014). Pathophysiology: the biological basis for disease in adults and children, (7th ed.). St.
Louis, MO. Elsevier.
Murphy, K. (2011). Janeway’s immunobiology, (8th ed.). New York. Garland Science.
Noble, A., Johnson, R. & Bass, P. (2010). The cardiovascular system: basic science and clinical conditions, (2nd ed.).
Edinburgh. Churchill, Livingstone, Elsevier.
Pagana, K.D. & Pagana, T.J. (2013). Mosby’s diagnostic and laboratory test reference, (11th ed.). St. Louis, MO. Elsevier.
Smith, M.E. & Morton, D.G. (2010). The digestive system: basic science and clinical conditions, (2nd ed.). Edinburgh.
Churchill, Livingstone, Elsevier.
VanMeter, K.C. & Hubert, R. (2014). Gould’s pathophysiology for health professions, (5th ed.). St. Louis, MO. Elsevier.
© Endeavour College of Natural Health endeavour.edu.au 38
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